Provider Demographics
NPI:1922372101
Name:OTT, BETHANY (LPC MHSP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:OTT
Suffix:
Gender:F
Credentials:LPC MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TECH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-2747
Mailing Address - Country:US
Mailing Address - Phone:865-637-9711
Mailing Address - Fax:
Practice Address - Street 1:3845 HOLSTON COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:TN
Practice Address - Zip Code:37777
Practice Address - Country:US
Practice Address - Phone:865-380-5089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003099101Y00000X
TN3555101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018428Medicaid